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Home My Public Portal About5555 1/2 SANTA ANITA AVE_Plumbing__ .WORKER$'COMPENSATION DECLARATION APPLICATION F® PLUMBING PERMO I� I hereby affirm that I I sve a certificate of consent to self 76A667A ..:insure, a... certificate-of Workers Compensation Insurance, CE 817 REV. 10/81) �J or a certifiaed&copy thereof(Sec. Lab, C,) COUNTY OF LOS ANGELES BUILDING AND SAFETY 'P❑olicy No?I Q Company // Certified copy is hereby furnishe �)1 BUILDING . FOR APPLICANT TO FILL IN(PRINT OR TYPE) .- Certified copy is filed with the.county building inspec- ADDRESS,�S ` tion department. /��, NUMBER FIXTURE OR ITEM @ FEE LOCALITY �� Date _ � Appl.i4ant / ZZ� 3 WATER CLOSET NEAREST 4001 CERTIFIC TE OF EXEMPTION FROM WORKERS' BATHTUB I I CROSS ST. COMPENSATION INSURANCE SHOWER OWNER D� (This section.need not be completed If the work Involved by MAIL S. AA `. , J the permit is for one hundred dollars($100)or less.) LAVATORY _ ADDRESS a• /,_AS 7_V I certify that in the performance of the work for which this �j permit is issued,I shall not employ any person in any manner SINK i Cl. TEL. �O so as to become subject to the Workers'Compensation Laws. DISHWASHER 61CONTRACT r Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should became subject. to the Workers' CITY TEL, C♦yJ Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM L ``� with comply with such provisions or this permit shall, be STATE LIC. deemed revoked. WATER HEATER _ LICENSE NO. CLASS . LICENSED CONTRACTORS DECLARATION DISTRICT NO. P OCESSED B I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /L (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (j and Professions Code,and p�myy�ilicense is in full force and.effect. 5 PER SYSTEM. FINAL VAL TIOII�I 3�� 6bY G_ DATE C License Number• Lic: Class rnFINA ContractorDate�_7_qBY IkC ❑ I am exempt under Sec. C BAP.C. for this reason 4 Plan check fee a Date: PLUMBING PERMIT ISSUING FEE$ Z Signature TOTAL FEE `J 1 Plan check applicant A 5 0&.5 A SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name # 0 0 0 0 0 5 I hereby affirm that I am exempt from.the Contractor's-License• Address• ° 10.200 Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. a a 102005 ❑ I; as owner of the property, will do the work and the structure is not intended or offered for sale (Section 0 7. 17-86 7044, Business and Professions Code). 1 CONSTRUCTION LENDING AGENCY I hereby off irm that there is a construction lending agency for ~ the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize and of this County to enter upon the a v -ment' ed property for inspection purposes. SEE(REVERSE FOR EXPLANATORY LANGUAGE C_ Signature of Permittee Date " VV(:)RKERS',COMPENSATION�DECLARATION APPLICATION F®R.Il"L�7AARIkJ`G !T"EIJ�f9� T I-hereby affirm that I have a certificate of consent to self, 76A667A insure, or 4 certificate df Workers'Compensation Insurance, CE 817(REV. 10/81) �+ or a certifi copy t ereof(Sec. 38Lab. G.) ` { COUF�iI Y OF LOS ANGELES BUILDING AND SAFETY Policy No. Company r / �/ ❑ Cart! led copy is hereby furnished-/ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ZCertified copy is filed with the cou building inspe ADDRESS tion department. 'ry��/- NUMBER f FIXTURE OR ITEM @ FEE LOCALITY r- Date Applicant// , /C�^C�IlN WATER CLOSET NEAREST �. CERTIFICATE OF EXEMPTION FROM WORKERS' p2 BATHTUB /dL CROSS ST. COMPENSATION INSURANCE / SHOWER OWNE'~ ` . , '(This section need not becompleted if the work involved by MAIL / � the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued,I shall,not employ any person in any manner SINK TEL. _ ?J� so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS �� NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption,'you should become subject to the Workers' CITY TEL. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STA LIC. C deemed revoked. , WATER HEATER LICENSE NO. CLASS / LICENSED CONTRACTORS DECLARATION DIST ICT N ROGESSED BY I hereby affirm-that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER D, and Professions Code,and my license is in full force and effect. S PER SYSTEM FINAL G DATE ®ATIOP@ License Number � Lic. Class �r FIN U Contractor :e Date r `� BY LLQ ❑ I am exempt under Sec. # B.BP.C. for this reason Plan check fee . 1 'a.l 0 2 0 0 �- Date-• Cn PLUMBING PERMIT ISSUING FEE$ b6d Z Signature aa10200C TOTAL FEE p 07. 17-86 Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address t Law for the following reason (Section 7031.5, Business and Professions.Code): City Tel. No. 1 ❑ I, as owner of the property, will do the work and the lr structure is not intended or offered for sale (Section 7044, Business and Professions Code). { CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for , the performance of the work for which this permit is issued � (Sec. 3097, Civ. C.). Lender's Name Lender's Address 1.certify that I have{read this application and state-that the above information,Wcorrect. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the aove-m ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of'Permittee Date''—